Translating the Clinical scenario into a Searchable … Information/pico.pdfTranslating the Clinical scenario into a Searchable Question: ... 2-A comparative study with ... IGg test

Translating the Clinical scenario into a Searchable Question:

Dr : Jarir AlabdelwahabDamascus 3/12/2010

By the year 2020, 90% of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and will reflect the best available reflect the best available evidence.

what's going on ?

1,500 per dayMEDLINE

5,000?per day

BIOMEDICAL 95 per dayTRIALS

Very few

(selected`)

keeping up to date (hunting skills)

THE BEST EVIDENCE

= Best Practice

The roadmap

Assess

Identify the clinical problem. What you

want to know?

WHAT INFORMATION DO NEED?

‘Background’?0R

‘Foreground’?

‘Background’ Questions

About the disorder, test, treatment, etc.what is the disorder; what causes it; how does it present; what are some treatment options.-2 components:

a. Root* + Verb: “What causes …” a. Root* + Verb: “What causes …” b. Condition: “… SARS?”

Resources of the answers :

textbooks and narrative reviews in journals

‘Foreground’ Questions

About patient care decisions and actionsspecific questions / specific patientAnswers from :

primary sources such as primary sources such as original research articles published in journals;

secondary sources such assystematic reviews of the topic, and synopses and reviews of individual studies

Background & Foreground

Participants

Exposure Group Comparison Group

P

E C

before asking question??? the 5 parts of every epidemiological study

Exposure Group Comparison Group

OutcomesTime

E C

O

T

The objective of most clinical studies

Common design Objective

Cross sectionalPrevalence

Cohort Incidence

Cohort, case-control, cross sectionalCause

CohortPrognosis

Controlled trial Treatment effect

questions1. What is the question (PICO) of the study ( anatomy)?

?What Kind of Question Is It?.2

a- interventionb- frequency (incidence or prevalence) c- diagnostic accuracy d -prognosis (or natural history)c- diagnostic accuracy d -prognosis (or natural history)e -aetiology and risk factors

3-Which study type would give the highest quality evidence to answer the question?

4-Translating the Clinical Question into a Searchable Question

Patient or population

Age range -Gender -race, Disease characteristics -Risk factors -medical condition(s)

Treatment, diagnostic test, exposure, screening

Intervention / Indicator

Anatomy of the Question?

P

I

Nothing, placebo, gold standard, another intervention, usual care

Hospitalizations, Mortality rate -symptom reduction, survival, Number of days lost from work quality of life

Comparison

Outcomes (preferably clinical)

C

O

Question Structure: PICO

nterventionI ComparisonPatients

Outcomes

Page 24

Risk Factors: Do patients with x disease have higher mortality?

ndicatorI ComparisonPatients

Outcomes

Page 24

Predictors, Risk Factors, tests

Question /prognosis

Type of treatmentType and severity of the diseaseCause of the diseaseTime of onsetTime of onsetSpecific measure of future risk(using survival curves) which allows estimation of disease-specific survival.

Question /diagnosis

performance characteristics of diagnostic tests: Sensitivity Specificity Likelihood ratiosLikelihood ratios(When we are most concerned about a false negative finding,

test sensitivity is most important.)

Specific test name and methodology(e.g. ELISA, Western Blot, electrophoresis) etc

What type of question is this?

DOMAINS

The kind of question you are asking will affect:

-how you use particular resources.

-the kind of answer you need.-the kind of answer you need.

- AND the way you analyze the studies you find.

The “best” evidence depends on the type of question

AetiologyPrognosisDiagnosis InterventionLevel

A systematic review

A systematic review

A systematic review

A systematic review I

A prospective cohort study

A prospective inception cohort study

Cross-sectional study

A randomised controlled trialII

A retrospective cohort study

untreated control patients in a randomised controlled trial

Cross-sectional study

1-A pseudo-randomised controlled trial2-A comparative study with concurrent control group3-A comparative study without concurrent control group:

III

A cross-sectional study

Case series, or cohort study

Case seriesCase series IV

Example

A 43 year old male asked for some repeat prescriptions and advice about preventing deep vein thrombosis on a 12 hour flight (his brother had had one last year). You suggest stockings as the most effective prevention.effective prevention.

P I CO

P : patients on long flights

I : compression stockings compression stockings

C: no compression stockings

O: prevent Deep Vein Thrombosis (DVT)

WHAT IS THE Clinical Question

In people who take long- flights does wearing compression stockings prevent DVT?

What type of question is it ?

What a searchable question might be?

Does wearing compression stockings prevent DVT?

what search terms would be suitable ?

compression stockingsDVTprevention

Example 3A 7-year old male presents with severe lower right quadrant pain.You suspect appendicitis following your initial examination.examination.You decide to send the patient for an ultrasound before you make your diagnosis.

PICOP=7-year old healthy male I=UltrasoundC=Physical examinations and CBC O=O=Accurate diagnosis to rule in or rule out appendicitis

WHAT IS THE CLINICAL QUESTION (How effective is ultrasound in accurately identifying acute appendicitis? )

SERCH TERMS could be :appendicitis AND ultrasound

case1•A 35 year old former intravenous drug user has been

found to be HCV RNA positive He last injected drugs 10 years ago after a 3 year period of needle sharing.

•He is sent to see you for advice on treatment for his viral hepatitis.

•A liver biopsy reveals periportal inflammation, some •A liver biopsy reveals periportal inflammation, some piecemeal necrosis and early fibrosis. He drinks 30 units of alcohol per week.

•He wants to know if he should have treatment and if so, does combination therapy of interferon with ribavirin really offer much more chance of viral clearance than interferon alone or just waiting to see what happens.

case 1/P I COP: 35 year old man who is HCV RNA positive I:interferon + ribavirinC:interferon or no treatmentO:viral clearanceviral clearance

For our patient, the clinical question might be:

“In 35 year old man who is HCV RNA positive does treatment with interferon + ribavirin, compared to interferon alone, or no treatment, offer a significant chance of viral clearance.

case 1/ searchable QDoes combined treatment with interferon + ribavirin for HCVRNA positive patients has a higher viral clearance rate than treatment with Interferon alone?

Search terms :HCVRNA positivityinterferoninterferonribavirinviral clearance

what type of question is it?a- interventionb- frequency (incidence or prevalence) c- diagnostic accuracy d -prognosis (or natural history)e -aetiology and risk factors

Example 2A 64-year-old white female with a long history of poorly treated hypertension was diagnosed by your preceptor with congestive heart failure (CHF) at her last visit.She was treated with a diuretic and started on an ACE inhibitor and now is clinically well compensated and without edema. Her EKG shows LVH and strain. Her echocardiogram shows an ejection fraction of 35% and left ventricular Her echocardiogram shows an ejection fraction of 35% and left ventricular hypertrophy. The patient is otherwise in good health without any other known chronic conditions.She is a lifelong non-smoker with a cholesterol/HDL ratio of 2.3 (low risk for heart disease). Her only other medication is Prempro (a combination estrogen/progesterone product).The patient has heard that CHF is a serious disease, and asks what the future is likely to hold for her. Specifically she asks how likely she is to die from this condition in the near future.

clinical question

's60women in their For white congestive moderately severe systolicof recent onsetwith

heart failure (ejection fraction around 30%) due to , hypertension

years after 10 , and 5, 2percent have died from CHFwhat years after 10 , and 5, 2percent have died from CHFwhat optimally with an ACE diagnosis, assuming they are treated

?as neededinhibitor and other medications

Translating the Clinical Question into a Searchable Question:

Identify the two or three most important concepts in our clinical question:

white women in their 60'scongestive heart failurecongestive heart failurewhat percent have died

The searchable question that could be asked:What is the prognosis for 60-year-old women with congestive heart failure?

Example 4A 52-year old woman presented with a three-week history of epigastric aching pain, worse in the early morning before breakfast and somewhat relieved by food and antacids. Physical examination was normal. An air contrast upper GI showed a small duodenal ulcer crater and mild reflux with provocative maneuvers. Her symptoms responded well to omperazole 40 mg. per day. H. pylori antibody serology was negative.antibody serology was negative.You are concerned about a possible false negative H. pylori serology because this would cause you to miss the opportunity of treating the patient for H. pylori and preventing future ulcers. Therefore, you decide to check on the sensitivity of the H. pylori assay used by the hospital laboratory.A laboratory technician informs you that the test they use is an ELISA, IGg test performed using a commercial kit.

Pico/example 4

P :,older women with symptomatic duodenal ulcer

I :IGg ELISA testIGg ELISA test

C :O :

sensitivity for detecting H. pylori infection

The clinical question

older women with symptomatic duodenal Among IGg of a typical sensitivity, what is the ulcer

for detecting H. pylori infection?ELISA test

the searchable questionthe searchable questionIs the IgG ELISA test sensitive for detecting H. pylori infection?

Search terms : IgG ELISA test ,H. pylori infection?

CASE 2A 67 years old woman and has a history of congestive heart failure brought on by several myocardial infarctions.

She has been hospitalized twice within the last 6 months for worsening of heart failure.

At the present time she remains in normal sinus rhythm. She is extremely diligent about taking her medications (enalapril, aspirin and simvastatin) is extremely diligent about taking her medications (enalapril, aspirin and simvastatin)

and wants desperately to stay out of the hospital.You think she should also be taking digoxin but you are not

certain if this will help keep her out of the hospital. You decide to research this question before her next visit

CASE 2/ P I C OP: congestive heart failure, elderlyI: digoxinC : C : none, placeboO: primary: reduce need for hospitalization;secondary : reduce mortality

For our patient, the clinical question might be:

In elderly patients with congestive heart failure, is digoxin effective in reducing the need for rehospitalization?

1-WHAT TYPE OF QUESTION IS IT ?1-WHAT TYPE OF QUESTION IS IT ?

2-WHAT THE SEARCH TERMS ARE?

congestive heart failureDigoxinhospitalization

The last massage

*"Kill as Few Patients as Possible" –*"Kill as Few Patients as Possible" –Oscar London

Thank you for joining in

Questions Questions or comments?